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S. Y. Vetter and U. Vieweg
• Shoulder dislocation
• A common complication of the prone position is increased
bleeding, mostly due to damage to engorged vertebral veins
21.11 Positioning inSpinal Surgery
The most common forms of positioning in spinal surgery are:
The Prone Position (see Fig.21.3a–c)
• Used mainly for posterior procedures requiring access to
the thoracic and lumbar spine.
The Lateral Position (see Fig.21.4a, b)
• Used generally for anterior access to the thoracic and
lumbar spine.
The Supine Position (see Fig.21.5a, b)
• Used for procedures requiring access to the anterior cervical, thoracic and lumbar spine.
The da Vinci Position (see Fig.21.6)
• Used for procedures requiring access to the anterior lower
lumbar/sacral spine.
c
Fig. 21.3 (a–c) Patient in prone position on operating table with head ring (a) position of the legs (b) and (c) with horseshoe-shaped headrest
Fig. 21.4 (a, b) Patient in lateral position for anterior lumbar/thoracic procedure
ab
21 Patient Positioning Techniques inSpinal Surgery
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Fig. 21.5 (a, b) Patient in supine position for anterior cervical spine procedure
• Thorax, pelvic and wedge cushions, padded roll
• Special bolster for the prone position
• Use adaptable arm positioning devices,
• Position the head on the special head positioning cushion,
• Position the axillae freely with the thorax pad and ensure
153
Positioning:
Positioning on a standard operating table (Fig.21.3a–c):
or skull-clamp
that the pelvic pad does not extend beyond the anterior
superior iliac crest.
21.11.1.2 Checklist forPosterior Surgical
Fig. 21.6 da Vinci position for anterior lower lumbar procedure
Intervention totheLumbar/Sacral
andThoracic Spine intheProne
Position
21.11.1 The Prone Position
21.11.1.1 Surgery intheThoracic andLumbar
Spine Areas intheProne Position
(See Fig.21.3a–c)
The prone position in which the patient is positioned headrst has traditionally been and remains the most common
position used to access the posterior aspect of the thoracical,
lumbar or sacral spine. The prone position is comfortable for
surgeons, providing an adequate overview of both bone and
neural structures in the treatment of fractures, deformities,
tumours, spondylodiscitis, spondylolisthesis and degenerative disc disease. The patient may be at risk of the development of pressure ulcers and nerve damage. The position
causes additional pressure for the skin and bony prominences. For this reason, positioning and, in particular, the
aids employed must take these effects into account. The
patient’s arms should be tucked at the patient’s sides with a
bed-sheet and secured with arm guards to sleds.
Preparations:
• Arm positioning devices
• Special head positioning cushion for prone position
Operating table: Radiolucent modular operating table
system
Positioning aids: Disposable sheet as underlay, towel as
stretch cover, gel head cushion, white disposable head cushion, two-arm positioning devices with gel pads for arms,
abdominal xation belt, body warming blanket, surgical cotton sheet as top cover, horseshoe-shaped headrest (foam or
silicone), silicone pads, half-roll, two to three tempur
pillows.
Important: The positioning should minimize the restriction of the abdomen. Attach ECG leads to the back. Provide
pressure ulcer prophylaxis, particularly in the region of the
patellae, the heads of the bulae, the toes, the iliac crest, the
chin, the eyes, nose and arms. Do not ex arms signicantly
beyond 90° (risk of plexus damage); upper arms must not be
constricted. Ensure male genitalia are not restricted and are
not subjected to pressure. Mammae must also not be subjected to pressure. Ensure head and cervical vertebrae are in
orthograde position. Use surgical site lm in the sacral region
to seal the anal cleft and prevent moisture collecting here,
thus avoiding the risk of burns.
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S. Y. Vetter and U. Vieweg
21.11.1.3 Checklist forDisc Surgery
andMicrosurgical Decompression
oftheLumbar Spine intheProne
Position
Table: Radiolucent modular operating table system
Positioning aids: Sheet as underlay, towel as stretch cover,
head gel cushion with surgical cap, white disposable head
cushion, one arm positioning device with gel pads, Ulmer
wheel, abdominal xation belt, body warming blanket, surgical cotton sheet as top cover, two-arm positioning devices,
gel cushions, gel mats, horseshoe-shaped headrest, silicon
pads, half-roll, positioning frame, two to three cushioning
pillows.
Important: Position iliac crest on the pelvic pad. Attach
buttock supports to the upper gluteal fold. The thorax cushion should not touch the chin and should not extend beyond
the lower end of the sternum. Patellae should not be restricted.
The anal fold must be sealed with lm to ensure that no
moisture can penetrate. Provide for pressure ulcer prophylaxis, particularly in the region of the patellae, the heads of
the bulae, the toes, the iliac crest, the chin, the eyes, the
nose and arms. Do not ex arms signicantly beyond 90°
(risk of plexus damage). Ensure male genitalia and Mammae
are not restricted. Ensure head and cervical vertebrae are in
orthograde position.
21.11.1.4 Posterior Access totheCervical Spine
withHorseshoe-Shaped Headrest
(Skull Clamp) intheProne Position
Indications are surgical procedures with posterior access to
the upper and lower cervical spine. The options for intraoperative, external repositioning of the patient are limited.
Preparations:
• Arm positioning devices
• Horseshoe-shaped headrest or skull clamp
Positioning:
• Prone positioning of the operating table in the theatre.
• Fix and pre-position the horseshoe-shaped headrest to the
head part of the operating table.
• Move the patient towards the head end until the shoulders
are at the upper edge of the operating table with the scap-
ulae still on the table.
• Position and x the head in the horseshoe-shaped
headrest.
• Position both arms along the body with arm protectors or
secure the arms, x in place with plasters if necessary.
21.11.1.5 Checklist forSurgery tothePosterior
Cervical Spine intheProne Position
Table: Extension table, carbon bre-top table
Positioning aids: Half-roll, gel cushions, footrest,
horseshoe- shaped headrest or skull clamp, arm extender,
Fixomull tape, brown Leukoplast tape, sheet for arm xation.
Important: Arm traction to improve lateral image quality
may be considered but handled with caution due to nerval
damage, especially of the C5 root. Cushioning in particular
of the feet and the face are mandatory to avoid pressure
caused ulcers (see Figs.21.5 and 21.6).
21.11.2 Lateral Position
The indications for spinal surgery in the lateral position include
procedures addressing the ventral column like interbody fusion
or vertebral body replacement. For lateral positioning, the
patient is placed either on the left or right side, depending on
the side of the surgical access (Fig.21.4a, b). The head should
be placed in a pillow or head positioner and the positioning of
the ear should be monitored. The patient’s physiological spinal
and neck alignment should be maintained during the procedure, and a safety restraint should be secured across the hips.
Risks to a patient in the lateral position include pressure to
points on the dependent side of the body, such as ears, shoulders, ribs, hips, knees and ankles, as well as brachial plexus
injury, venous pooling and diminished lung capacity.
21.11.2.1 Checklist forSurgery Requiring
Access toThoracic/Lumbar Spine
intheLateral Position
Table: Radiolucent modular operating table system
Positioning aids: Sheet as underlay, towel as stretch cover,
gel head cushion with surgical cap, white disposable head
cushion, two-arm positioning devices with gel pads for arms,
Ulmer wheel, abdominal xation belt, two body warming
blankets, surgical cotton sheet as top cover, backrest, one
three-sectioned support, two two-sectioned supports, three
gel pads, disposable tunnel cushion.
Important: Attach upper arm at 90° to specially padded
anaesthesia screen, sheets in the ank, legs parallel and padded with cushions and gel mats. Provide for pressure ulcer
prophylaxis, particularly in the region of the trochanters,
malleoli, calcanei and head of the bula. Do not ex arms
beyond 90° and do not position below the thorax (risk of
21 Patient Positioning Techniques inSpinal Surgery
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155
plexus damage). Ensure the head is in orthograde position
(risk of impaired blood perfusion). Ensure male genitals, in
particular, are not restricted.
21.11.3 Supine Position
21.11.3.1 Checklist forSurgery totheCervical
Spine intheSupine Position
(Fig.21.5a, b)
Table: Radiolucent modular operating table system
Positioning aids: Gel pads, half-roll, footrest, head ring,
gauze dressings, Fixomull tape, brown Leukoplast tape,
sheet for arm xation, arm extender, backrest. Place a towel
roll under the cervical spine or scapula. Extension of the
arms ensures intraoperative uoroscopy of the cervical spine
is possible without superimposition of the scapulae. Provide
pressure ulcer prophylaxis, particularly in the region of the
heels, the elbows, the buttocks
21.11.4 Checklist forSurgical Procedures
Requiring Access totheLower
Lumbar Spine intheda Vinci Position
(Fig.21.6)
3. McCulloch JA, Young PH. Microsurgery for lumbar disc herniation. In: McCulloch JA, Young PH, editors. Essentials of spinal
microsurgery. Philadelphia: Lippincott; 1998. p.329–82.
4. Lipton S.Anesthesia in the surgery of retropulsed vertebral discs.
Anaesthesia. 1950;5:208–12.
5. Tarlov IM.The knee chest position for lower spinal operations. J
Bone Joint Surg Am. 1967;49:1193–4.
6. Wayne SJ.The tuck position for lumbar disc surgery. J Bone Joint
Surg Am. 1967;49:1195–8.
7. Ray CD.New kneeling attachment and cushioned face rest for spinal surgery. Neurosurgery. 1987;20:266–9.
8. Stephens GC, Yoo JU, Wilbur G. Comparison of lumbar sagittal alignment produced by different operative positions. Spine.
1996;21:1802–6.
9. Hastings DE.A simple frame for operations on the lumbar spine.
Can J Surg. 1969;12:251.
10. Relton JE, Hall JE. An operation frame for spinal fusion. A new
apparatus designed to reduce haemorrhage during operation. J
Bone Joint Surg Br. 1967;49:327–32.
11. NICE. Clinical-practice-guideline, the management of inadvertent perioperative hypothermia in adults. National Collaborating
Centre for Nursing and Supportive Care commissioned by National
Institute for Health and Clinical Excellence (NICE). 2007. http://
guidance.nice.org.uk/CG65. Accessed 23 Jan 2015.
12. Torossian A, Bräuer A, Höcker J, etal. Clinical practice guideline:
preventing inadvertent perioperative hypothermia. Dtsch Arztebl
Int. 2015;112:166–72.
Suggested Reading
Table: Radiolucent modular operating table system
Positioning aids: Sheet as underlay, towel as stretch cover,
gel head cushion with surgical cap, white disposable head
cushion, two-arm positioning devices with gel pads for arms,
Ulmer wheel, abdominal xation belt, body warming blanket, surgical cotton sheet as top cover.
Important: Provide for pressure ulcer prophylaxis, particularly in the region of the buttocks and heels. Position gel
cushions under both legs. Do not ex arms beyond 90° and
do not position below the level of the thorax (risk of plexus
damage). Ensure head and cervical vertebrae are in orthograde position.
References
1. Batson OV. The function of vertebral veins and their role in the
spread of metastases. Ann Surg. 1940;112:139–49.
2. Norgore M. Clinical anatomy of the vertebral veins. Surgery.
1945;17:606.
Ali AA, Breslin DS, Hardman HD, Martin G.Unusual presentation and
complication of the prone position for spinal surgery. J Clin Anesth.
2003;15:471–3.
Botsman O, Hyrkas J, Hirvensalo E, Kallio E.Blood loss, operating
time, and positioning of the patient in lumbar disc surgery. Spine.
1990;15:360–3.
Callahan RA, Brown MD. Positioning techniques in spinal surgery.
Clin Orthop. 1981;154:22–6.
Campbell K. Pressure points in the operating room. J Enterostomal
Ther. 1989;16:119–24.
Chu YC, Tsai SK, Chan KH, et al. Lateral medullary syndrome
after prone position for general surgery. Anesth Analg. 2002;
95:1451–3.
DiStefano VJ, Klein KS, Nixon JE, Andrews ET.Intra-operative analy-
sis of the effects of position and body habitus on surgery of the low
back. A preliminary report. Clin Orthop. 1974;99:51–6.
Ecker A.Kneeling position for operations on the lumbar spine. Surgery.
1949;25:112.
Ford LT.Position for lumbar disc surgery. Clin Orthop. 1977;123:104.
Guanciale AF, Dinsay JM, Watkins RG.Lumbar lordosis in spinal
fusion. A comparison of intraoperative results of patient position-
ing on two different operative table frames. Spine. 1996;21:964–9.
Keim HA, Weinstein JD. Acute renal failure. A complication
of spine fusion in the tuck position. J Bone Joint Surg Am.
1970;52A:1248–51.
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Knight DJW, Mahajan RP. Patient positioning in anesthesia. Contin
Educ Anesth Crit Care Pain. 2004;4(5):160–3.
Krettek C, Aschemann D.Positioning techniques in surgical applica-
tion. Heidelberg: Springer; 2006.
McNulty SE, Weiss J, Azad SS, etal. The effect of the prone position on
venous pressure and blood loss during lumbar laminectomy. J Clin
Anesth. 1992;4:220–5.
Ogbue MN, Jefferson P, Ball DR.Perioperative peripheral nerve injury.
Anaesthesia. 2001;56:393–4.
Park CK.The effect of patient positioning on intraabdominal pressure
and blood loss in spinal surgery. Anesth Analg. 2000;91:552–7.
Papantonio C, Wallop JM, Kolodner KB.Sacral ulcers following cardiac
surgery: incidence and risks. Adv Skin Wound Care. 1994;7:24–36.
Pearce DJ. The role of posture in laminectomy. Proc R Soc Med.
1957;50:109.
Phillips NF. Berry & Kohn’s operating room technique. 10th ed. St.
Louis, MO: Mosby; 2004.
Prielipp RC, Morell RC, Buttworth J.Ulnar nerve injury and periopera-
tive arm positioning. Anesthesiol Clin North Am. 2002;20:351–65.
Schonauer C, Bochetti A, Barbagallo G, etal. Positioning on surgical
table. Eur Spine J. 2004;13(Suppl 1):S50–5.
Servant C, Purkiss S. Positioning patients for surgery. Cambridge:
Cambridge University Press; 2002.
Sessler DI. Complications and treatment of mild hypothermia.
Anesthesiology. 2001;95:531–43.
St-Arnaud D, Paquin M. Safe positioning for neurosurgical patients.
AORN J. 2008;87(6):1156–72.
Sutterlin C, Rechtine GR.Using Hefngton frame in elective lumbar
spinal surgery. Orthop Rev. 1988;17:597–600.
Tao-Chen L, Lin-Cheng Y, Han-Jung C. Effect of patient position
and hypotensive anesthesia on inferior vena cava pressure. Spine.
1998;23:941–7.
Part II
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Anterior Upper Cervical Spine
Overview ofSurgical Techniques
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andImplants fortheAnterior Upper
Cervical Spine
MeicH.Schmidt
22
22.1 Introduction and Core Messages
The upper cervical spine represents a unique biomechanical and anatomic region that requires specialized surgical techniques and implants. Most commonly, the upper
cervical spine is affected by trauma (odontoid fractures
and nonunions), occipital-cervical dislocations, or
degenerative processes, particularly rheumatoid arthritis,
which results in atlantoaxial instability. Trauma indications include Jefferson fractures with instability and disruption of the transverse ligament, odontoid fractures
that are mobile in exion and extension, and C1–2 dislocations. In rheumatoid degenerative instability of the
C1–2 joints, the indications are also inclusive of decompression of the spinal cord and then subsequent stabilization. The four most common surgical techniques for the
region are anterior odontoid screw xation, transoral
resection of the odontoid process, posterior C1–2 xation, and anterior transarticular screw xation [1–4].
22.2 Approaches
Approaches and implants for the anterior upper cervical
spine are complex, corresponding to the unusual biomechanical and anatomic arrangement of that part of the spine. Some
of them are not recommended as a stand-alone technique.
Frequently, for example, a transoral resection of the odontoid
is performed in conjunction with a posterior cervical fusion.
Anterior approaches to the upper cervical spine are frequently based on modications of the standard approach for
anterior cervical discectomy and fusion, which is extended
toward the head (cephalad).
22.2.1 Transoral Approach
There are two common transoral approaches for the
treatment of rheumatoid arthritis or fracture/instability. The
transoral resection is more commonly performed in rheumatoid disease for decompression of the spinal cord. This
is frequently done through the mouth if the patient is able
to open the mouth widely enough (Fig.22.1). It requires a
specialized retractor system, as described in Chap. 17. We
do not usually place instrumentation using this approach.
M. H. Schmidt (*)
Department of Neurosurgery, University of New Mexico,
Albuquerque, NM, USA
e-mail: MHSchmidt@salud.unm.edu
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_22
22.2.2 Extraoral Ventral Retropharyngeal
Approach
On rare occasions, a similar approach can be used for the
placement of anterior transarticular screws (see Chap. 16).
This can be done when there is C1–2 instability or an odontoid fracture (Fig. 22.2). The retropharyngeal approach is
used, and then bilateral transarticular screws are passed from
an anterior approach using a K-wire system. This can be
done in combination with an odontoid screw. Typically, this
procedure can also be done with K-wires and cannulated
screws, but the K-wires must be carefully monitored so they
do not migrate after insertion of the screws.
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Fig. 22.1 Photograph
showing transoral exposure
using the Spetzler–Sonntag
retractor
M. H. Schmidt
a b
Fig. 22.2 Computed tomography scans showing C2/3 fracture dislocation (a) and C2/3 anterior cervical discectomy and fusion (b) using a retro-
pharyngeal submandibular approach
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161
22.3 Implants
22.3.1 Screws
The screws used for xation in anterior approaches to the
upper cervical spine are varied and depend on the approach
used. With odontoid screw xation, we use noncannulated
screws, although others advise against their use. For the retropharyngeal approach, bilateral transarticular screws are
typically used, sometimes in combination with an odontoid
screw. Cannulated screws can be used. Anterior transarticular screws should be lag screws since this will “lag” together
the C1/2 joint for fusion.
22.3.2 Plating
Anterior plating has been described but is rarely used. The
predominant indication is traumatic instability after C1 fracture or resection of the odontoid. The Harms plating system
has been described by Ruf etal. [1].
References
1. Ruf M, Melcher R, Harms J.Transoral reduction and osteosynthe-
sis C1 as a function-preserving option in the treatment of unstable
Jefferson fractures. Spine. 2004;29:823–7.
2. Russo A, Albanese E, Quiroga M, Ulm AJ.Submandibular approach
to the C2–3 disc level: microsurgical anatomy with clinical applica-
tion. J Neurosurg Spine. 2009;10:380–9.
3. Schmelzle R, Harms J.Craniocervical junction–diseases, diagnos-
tic application of imaging procedures, surgical techniques. Fortschr
Kiefer Gesichtschir. 1987;32:206–8.
4. Vender JR, Harrison SJ, McDonnell DE. Fusion and instrumenta-
tion at C1–3 via the high anterior cervical approach. J Neurosurg.
2000;92:24–9.
Odontoid Screw Fixation
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MeicH.Schmidt
23
23.1 Introduction and Core Messages
Anterior odontoid screw xation is ideal for xation of
unstable odontoid fractures and is superior to posterior
C1–2 arthrodesis as it preserves C1–2 rotational movement and obviates the need for autograft bone harvest.
This method has become increasingly popular since
the time it was introduced by Bohler [1], and it is now
widely used to treat unstable type II and shallow type
III odontoid fractures [2–9]. The goals of odontoid
screw xation are immediate stabilization of type II
odontoid fractures or shallow type III odontoid fractures with no need for external orthosis.
23.2 Indications
• Type II odontoid fractures
• Shallow type III odontoid fractures that have failed nonoperative treatment
• Elderly patients who have failed halo xation and external orthosis
• Patients that do not want to use halo xation or external
orthosis
23.3 Contraindications
• Severe associated C1 and C2 fractures
• Occipital cervical instability associated with type II odontoid fractures
• Fractures that are older than 18months
• Patients that have excessive cervical kyphosis
• Patients with a large chest (barrel chest)
• Anterior oblique fracture (see Fig.23.1a)
23.4 Technical Prerequisites
It is essential that the patient can be intubated beroptically
by an experienced anesthesiologist. Neuromonitoring,
including somatosensory evoked potentials (SSEPs) and
motor evoked potentials (MEPs), can be performed.
Awake nasotracheal or beroptic intubation is used if
there is instability in extension. Traditional laryngoscopic
intubation is safe if the fracture reduces in extension. We
highly recommend using two uoroscopy machines for
bilateral views simultaneously of the anterior-posterior (AP)
upper cervical spine and the lateral upper cervical spine.
Because we use the Aesculap anterior odontoid screw xation system, which allows for intraoperative reduction of the
odontoid fracture, we do not require complete preoperative
reduction of the fracture.
M. H. Schmidt (*)
Department of Neurosurgery, University of New Mexico,
Albuquerque, NM, USA
e-mail: MHSchmidt@salud.unm.edu
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_23
23.5 Planning, Preparation,
andPositioning
We routinely include the upper sternum and the neck in the
sterile preparation. The patient is placed in the supine position with head immobilized with 10lb of traction via a halter
device. Alternatively, Gardner–Wells tongs can be used or
halo traction can be used if the patient has already been in the
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